Minor Infraction Tracking Form Question Title * 1. Name of the student being referred? (Required.) Question Title * 2. Referring Teacher's name? (Required.) Question Title * 3. What date and time did the incident occur? (Required.) Question Title * 4. What number referral is this? (select only one) (Required.) Warning 1st minor referral 2nd minor referral 3rd minor referral 4th minor referral-- major referral--sent to office Question Title * 5. Where did the incident occur? (Required.) Question Title * 6. What type of minor infraction occured? (Select only one) (Required.) Class disruption Physical Contact/Horse Play Property Misuse Bullying/Harrassment Minor Disrespect Minor Profanity Uniform Violation Question Title * 7. What interventions did the teacher implement? (Required.) Student Conference Loss of Privilege Seating Change Remedial Work Parent Call Parent Conference Refer to Counselor Parent Call/Conference Date(s) Question Title * 8. What was a possible motivation for the student's behavior? (Required.) Avoid Adult Avoid Peers Avoid Task Obtain Adult Attention Obtain Peer Attention Obtain Items I Don't Know Other If "other" was selected please define Question Title * 9. Others involved? (Select only one) (Required.) None Peers Staff Teacher(s) Substitue Other If "other" was selected, please define Question Title * 10. Briefly describe incident. (Required.) Done